- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $3,981.07
| Facility | | $204.17 | $204.17 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $38.02
| Facility | 26 | $38.02 | $38.02 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $144.54 / $281.84
| Professional | | $114.82 | $144.54 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $23.99 / $52.48
| Professional | 26 | $12.88 | $23.99 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $120.23 / $234.42
| Professional | TC | $97.72 | $120.23 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $186.21 / $223.87
| Facility | | $177.83 | $186.21 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $245.47 / $257.04
| Professional | | $208.93 | $245.47 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $42.66 / $45.71
| Professional | 26 | $34.67 | $42.66 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $204.17 / $213.80
| Professional | TC | $162.18 | $204.17 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $218.78 / $281.84
| Professional | | $151.36 | $218.78 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $31.62 / $42.66
| Professional | 26 | $16.22 | $31.62 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $186.21 / $239.88
| Professional | TC | $131.83 | $186.21 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $194.98 / $354.81
| Facility | | $134.90 | $194.98 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $38.02
| Facility | 26 | $38.02 | $38.02 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $239.88 / $309.03
| Professional | | $125.89 | $239.88 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $37.15 / $51.29
| Professional | 26 | $19.50 | $37.15 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $208.93 / $263.03
| Professional | TC | $112.20 | $208.93 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $218.78 / $302.00
| Professional | | $186.21 | $218.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $34.67 / $48.98
| Professional | 26 | $29.51 | $34.67 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $186.21 / $281.84
| Professional | TC | $158.49 | $186.21 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $257.04
| Professional | | $117.49 | $117.49 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $20.89 / $38.02
| Professional | 26 | $20.42 | $20.89 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $97.72 / $213.80
| Professional | TC | $95.50 | $97.72 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $234.42 / $346.74
| Professional | | $141.25 | $234.42 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $25.12 / $45.71
| Professional | 26 | $16.22 | $25.12 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $204.17 / $316.23
| Professional | TC | $120.23 | $204.17 | $316.23 |